HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 196 SUMMER STREET 1/14/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of JAN 14 2021
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may be'used,but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location*4* ftr,-L-eft
/ �ig ront f ious Left/Right rear of house, Left/right side of house, Left 1
Right side of bui / t ono building, Left/Right rear of building, Under deck
Address ( C`
City/Town '( state Zip Code
2. System Owner. �I�^
Name'
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? afes ❑ No If yes, was it cleaned? Q-Ygg--�No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. ZSigne
e contents-were disposed:
Lowell Waste Water
OA
Date
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